What are the current guidelines for managing hypertension (high blood pressure)?

Current Guidelines for Managing Hypertension

According to the most recent 2024 European Society of Cardiology (ESC) guidelines, blood pressure should be lowered to a target of 120-129 mmHg systolic and 70-79 mmHg diastolic for most patients to reduce cardiovascular disease risk. 1

Blood Pressure Classification and Diagnosis

• Blood pressure is classified as non-elevated (<130/85 mmHg), high-normal (130-139/85-89 mmHg), and hypertension (≥140/90 mmHg) 1
• Diagnosis requires proper measurement technique using validated devices with the patient seated, arm at heart level, and at least two measurements at each visit 1
• Confirmation of hypertension should include home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg) 1
• When using ambulatory or home BP readings, values are typically 10/5 mmHg lower than office readings for both thresholds and targets 1

Treatment Thresholds

• Drug treatment should be started immediately in all patients with sustained systolic BP ≥160 mmHg or diastolic BP ≥100 mmHg despite non-pharmacological measures 1
• For patients with BP 140-159/90-99 mmHg, immediate drug treatment is recommended if they have:
  • Target organ damage
  • Established cardiovascular disease
  • Diabetes
  • Chronic kidney disease
  • 10-year cardiovascular disease risk ≥20% 1
• For lower-risk patients with BP 140-159/90-99 mmHg, lifestyle modifications should be tried for 3-6 months before initiating drug therapy if BP remains elevated 1, 2

Treatment Targets

• For most patients, the recommended target is systolic BP 120-129 mmHg and diastolic BP 70-79 mmHg 1
• For patients with diabetes, chronic kidney disease, or established cardiovascular disease, a lower target of <130/80 mmHg is recommended 1
• For elderly patients (≥85 years), those with orthostatic hypotension, or moderate-to-severe frailty, treatment targets may be less stringent but should still be maintained if well tolerated 1, 3

Lifestyle Modifications

• Lifestyle modifications are recommended for all patients with elevated BP and should be continued even when drug therapy is initiated 1, 4
• Effective lifestyle interventions include:
  • Weight reduction to achieve a healthy BMI (20-25 kg/m²) 1, 4
  • Adoption of the DASH or Mediterranean diet 1, 5
  • Sodium restriction and increased potassium intake 2, 4
  • Regular physical activity (150 minutes/week of moderate aerobic activity plus resistance training 2-3 times/week) 1, 5
  • Alcohol limitation (≤100g/week, preferably none) 1, 2
  • Smoking cessation 1, 2

Pharmacological Treatment

• For most patients with confirmed hypertension (≥140/90 mmHg), combination therapy is recommended as initial treatment 1, 3
• The preferred initial combination is a renin-angiotensin system (RAS) blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker or a thiazide/thiazide-like diuretic 1, 3
• Fixed-dose single-pill combinations are recommended to improve adherence 1, 3
• For black patients, initial therapy should include a calcium channel blocker or thiazide-like diuretic, with or without an ARB 1
• If BP is not controlled with a two-drug combination, a three-drug combination is recommended (RAS blocker + calcium channel blocker + thiazide/thiazide-like diuretic) 1
• Beta-blockers should be used when there are specific indications such as angina, post-myocardial infarction, or heart failure 1
• Combining two RAS blockers (ACE inhibitor and ARB) is not recommended 1

Special Populations

• Diabetes: Start drug treatment if BP ≥140/90 mmHg with a target of <130/80 mmHg; preferred regimen includes a RAS inhibitor 1
• Chronic Kidney Disease: Target BP <130/80 mmHg with a RAS inhibitor as part of the regimen 1
• Elderly: Maintain treatment if well tolerated, even beyond age 85; consider more gradual BP lowering and monitor for orthostatic hypotension 1
• Resistant Hypertension: Consider adding spironolactone or, if not tolerated, amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Monitoring and Follow-up

• After treatment initiation, patients should be seen every 1-3 months until BP is controlled 3
• BP should ideally be controlled within 3 months 1
• Regular monitoring of both office and home BP readings is recommended 3
• Annual reassessment of cardiovascular risk is recommended 3

Common Pitfalls to Avoid

• Failing to confirm office BP readings with home or ambulatory monitoring before initiating treatment 1
• Using inappropriate cuff size, which can lead to inaccurate readings 1
• Not accounting for white coat hypertension or masked hypertension 1
• Initiating monotherapy in patients with confirmed hypertension ≥140/90 mmHg (except in low-risk, elderly, or frail patients) 1
• Discontinuing lifestyle modifications after starting drug therapy 4
• Not considering cultural factors that may affect adherence to lifestyle modifications 6